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Proactive Primary Care Evaluation Summary

Summary of Findings:

Patients became significantly healthier as a result of PPC. After three telephone care
calls, the self-assessed general health score, where 10 is the best and 1 is the worst,
increased from 6.58 to 7.10 (p = 0.000).
Patients significantly improved their health behaviour. 68% of the patients
transformed their health-compromising behavior to health-enhancing behavior, such as
doing exercises, eating healthy and keeping optimistic.
Patients rated the project highly in providing motivation for self-management,
someone to talk to and information about community services. Less benefit was
seen in enhancing their health knowledge.
PPC reduced anxiety by 21%
The average monthly number of GP appointments by this population increased by
about 11% (p = 0.000) and there was a significant increase of 38% (p = 0.000) in the first
month after the start of the project.
The average monthly number of telephone consultations from this population
increased by about 20% 0p = 0.038).
There was no significant change in the number of home visits.
The average monthly outpatient attendances were reduced by about 27% (p =
0.005). Patients appeared to transfer their health activity from secondary to primary care.
The unit cost per patient is about 40. The estimated net cost of a 6-month Proactive
Primary Care project involving 683 patients, taking changing utilisation into account, is
about 24,422.

Introduction
Lewisham CCG carried out a Proactive Primary Care (PPC) project as one of its strategic
priorities: providing better support for patients with long term conditions (LTCs). The
programme is based on a Michigan study which showed significant improvements in health
behaviour following telephone support to patients with LTCs.
We targeted patients with two or more LTCs gathered from practice lists. Practices can
exclude inappropriate patients and add others they think will benefit. Patients are called three
times over three months by trained telephoners using motivational interview techniques.
They focus on the issues that matter to patients and do not push a particular health agenda.
They explore:
The patients current health
Their confidence in managing rapid deterioration in their condition
What health issues people would like to tackle and supporting them in doing that
Linking patients with relevant local third sector or statutory agencies where helpful.
The feasibility of the approach was tested in a PPC Pilot study in 2012 with 70 patients from
Honor Oak Group Practice. After making some adjustments recommended by local practices,
the second stage began in Jan 2014, with five GP practices across Lewisham (Woolstone
Medical Centre, St Johns Medical Center, Rushey Green Practice Group, Amersham Vale
Training Group and Vesta Road Surgery).
Control group
Patients with two or more long term conditions were involved in the test group and another
group of patients with similar health conditions were included in the control group. The control
group was not contacted by anyone. Their notes were searched for use of NHS services, so

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that we could gauge whether the project impacted on service utilisation.

Impact on health
Patients were asked to evaluate their health status as improving, the same or worsening. The
proportions of each status derived from the three calls are shown in Table 1.

TABLE 1: health status assessment distribution of the three calls

1st call (N=282)
2nd call (N=287)
The same
57%
75%
Worsening
31%
9%
Improving
12%
15%

3rd call (N=271)

73%
10%
17%

Compared with the baseline 1st call, patients felt their health not only improved but stopped
getting worse. Statistically, the improvements between the first call to the third are extremely
significant (p<0.001)

Health behaviour change

In total, 68% changed their behavior to keep healthy.
Awareness and understanding of their conditions
41% of the patients did not agree that PPC had helped them to better understand their LTCs,
since they had already understood their symptoms well.
Ability and confidence to manage their conditions
We had hoped that PPC would help people manage emergencies better and with more
confidence. However, respondents appeared already confident and well-informed and did not
need extra assistance. These questions can probably be left out in future.
Impact on lifestyle and health behaviour
35% ate more healthily to lose weight
26% did more walking
27% do more exercises and joined local exercise classes
23% were more active about their lives and went out to meet new friends
12% of smokers were making an effort to stop smoking
Over 50% of the patients said that they would like to make some changes to their lives as a
result of a PPC suggestion. PPC encouraged people to be more active in respect of their
LTCs. The majority of the patients are older people who had little knowledge of local health
services at the beginning of the PPC project. Service information offered provided them
opportunities to make new friends and take part in local activities.
PPC reduced anxiety by 21%
The percentage of feeling anxious dropped from 34% to 27%. This is an important effect.

Evaluation of PPC service and support

Over 90% of the patients gave positive feedback about PPC and as time went by, slightly
more patients thought the telephone care calls would benefit their LTCs (p=0.002).
PPC was seen as useful in the following three ways:
Provision of information about the services and programs available in local
community (21%)
Motivation and reminders to manage their LTCs (24%)
Having someone to talk to (38%)
It is a bit surprising that only 12% of the patients thought of loneliness as a problem and even

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fewer (7%) thought that having someone to contact was helpful in the first call. Nevertheless,
by the end of the project, 38% of the patients showed great gratitude to the callers. The
telephone calls made them feel that people were concerned about them.

Referral to third sector and NHS groups outside primary care

PPC also seems to have helped people to change their health behaviour by providing
information about local community groups. 39% of the patients took part in community health
services and third sector groups.

Clinical service utilisation

Clinical service utilisation was measured before and after the baseline for both primary and
secondary care:
Impact on primary care
- GP visits
- Telephone consultations
- Home visits
Impact on secondary care
- Outpatient attendances
- Hospital admissions
The average monthly number of GP appointments increased by about 11% (p = 0.000)
with an increase of 38% (p = 0.000) in the first month. After three months, the difference
between the intervention and control group decreased.
After being phoned by PPC callers, some patients seemed to attend the GP soon. Some
patients required a GP appointment during the call and went to the surgery within one week.
Some older patients have trouble in making appointments, and the callers helped them.
The average monthly number of practice telephone consultations increased by about
20%. Again, this decreased over time. In the first month, the number of telephone
consultations was 0.036 more than before the intervention and in the second month, this
increment decreased to 0.033 and kept stable at 0.014 thereafter.
There was no significant change in the number of home visits. But the numbers are
small.
The average monthly outpatient attendances were reduced by about 27% (p = 0.005).
Outpatient attendances were reduced by 0.0389 per month (p = 0.005). From year 2013 to
2014, the average monthly outpatient attendance increased from 0.0455 to 0.0705 in the
control group, while it decreased from 0.0527 to 0.0386 in the intervention group. This
reduction in hospital visits is very statistically significant.

Motivational Caller experience

Throughout the pilot I found it was mixed emotions on whether they felt this project would
help them. At the end of the project I found It depended on the individual at the time of their
lives and how serious their actual long term condition was.
-

A middle aged man who felt really trapped and housebound, but after talking to us he
had found an exercise class for amputees in his local area.

A man who had been a recluse for many years getting the courage to get a voluntary
job 1 day a week in a charity shop.

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A woman suffering with depression feeling cared about and joining weight watchers
and walking groups even making friends and getting a new job. She feels the calls
were like prompts to change her lifestyle and social life .

I was able to intervene when a patient was facing eviction and liaised with the
housing and the patient. There was an on-going history with the patient/housing due
to anti-social behaviour. The patient was expected to attend a meeting but she was
seriously depressed, not well and had heart problems. I was able to talk with both
parties and set up an amicable meeting.

Overall cost benefit

Taking the changing demand for services into account, the net cost of PPC for 638 patients is
about 24422 with a cost per patient of about 40 with 8,578 saving on clinical utilization.
The saving on service utilisation does not cover the cost of the telephone calls.
The cost and saving of PPC is evaluated on a half-year basis, where the telephone calls are
made in the first three months. It is assumed that the interval between telephone calls is one
month and no intervention effect will last more than a half year. Based on actual information
that 660 calls were made in 103 working days, 2049 calls can be made by 5 callers in 3
months. This would cost about 33k.

Conclusion
Evaluating key aspects through a control group gives these outcomes a rare robustness.
PPC improved patients general health and improved their health behavior and lifestyle.
Patients appeared to transfer their health activity from secondary to primary care which
reduced health spend on secondary care. Patients found PPC helpful and actively used
referrals to the third sector. PPC reduced patient anxiety by over 20%.
The PPC approach to risk stratification and intervention makes a positive impact and should
be considered for extension and dissemination.

-------------------------------------------------------------------------------------------------------------------------Acknowledgements
The Evaluation of the Proactive Primary Care Project was commissioned and is currently
overseen by PPC Project Chair (Dr Brian Fisher) and Lewisham CCG Lead (primarily Marie
Searle). With thanks to the dedication and commitment of the telephone callers; to Paul
Chapman who designed the IT data collection system; and to the LSE students and staff
supervisors.